Mr G.I. Bain, 206 Melbourne Street, North Adelaide, South
Gregory I. Bain, Hari Prem., Ronald J Heptinstall, Rik Verhellen,                                                                                                                                                                                Australia, Australia 5006.
Deborah Paix
                                                                                                                                                                                                                                                 Phone: (618)8361 8399. Fax:(618)8239 2237. e-mail:
Modbury Public Hospital, Adelaide, South Australia, Australia.
Royal Adelaide Hospital, Adelaide, South Australia, Australia.                                          DISCUSSION
                                                                                                        Simple Techinque:
Most authors currently recommened an anatomic repair of the rupture distal biceps tendon report a       The only surgery performed in the depth of the wound is the preparation of the radial tuberosity,
                                                                                                        which is performed with the elbow in full extension and supination.
new technique of distal biceps tendon repair using an internal button - the Endobutton (Acufex).
                                                                                                        The tendon is sutured to the Endobutton. At this point it is “prefabricated” and the Endobutton

                                                                                                        delivers and locks the tendon into position.

OPERATIVE TECHNIQUE                                                                                     Synostosis:
                                                                                                                                                                                                                                                 Fig 2c. Trailing suture locks Endobutton into sub-periosteal space.
                                                                                                        R-U synostosis has been reported with the two-incision technique but not with an anterior
Exposure                                                                                                approach.3,5,7

A transverse skin incision 2 cm distal to the elbow skin crease was made and the lateral antebrachial   Nerve Injury:
cutaneous nerve was protected. In acute cases the the retracted biceps tendon and the tendon tract
                                                                                                        Our dissections and experience demonstrate the anterior approach is safe once in the inflaatory bursa,
were readily identified. With the elbow in full extension and supination, the radial tuberosity was
                                                                                                        it is necessary to expose the neurovascular structures.
exposed. A cortical window to accommodate the tendon was made with a burr. A drill was advanced

across the opposite cortex.
                                                                                                        The Endobutton is robust and easily accommodates number 5 Ethibond to allow active mobilisation.
Fixation of tendon to the Endobutton
The Endobutton is a 4 x 12mm flat titanium implant developed for graft fixation of ACL                                                                                                                                                           Fig 3. Cross-section of proximal forearm with relationship of major nerves to biceps tendon.
                                                                                                                                                                                                                                                 Steinman pin advanced through posterior forearm

The tendon is fixed to the Endobutton with Number 5 Ethibond Bunnell sutures placed in the medial                                                                                                                                                  TECHNIQUE                       Author            Incisions                Tendon                Radial N    R-U                                  Skin      Early Simplicity
                                                                                                                                                                                                                                                                                                                              Position               Injury? Synostosis                            Necrosis    Motion
and lateral margins of the tendon (Fig 1).

                                                                                                                                                                                                                                                                                Boyd and
In th one late case an extensive anterior approach was performed and a semitendonosis graft                                                                                                                                                       2-Incision                    Anderson,                    2           Osteoperiosteal                     -                    +                    -              -         -
                                                                                                                                                                                                                                                  Technique                     Morrey                                   flap
interwoven through the tendon. The Endobutton wasthen attached to the graft.
                                                                                                                                                                                                                                                  External                      Louis,                       1           Medullary                          +                     -                   +               -         +
Advancement of the Endobutton                                                                                                                                                                                                                     Button                        Norman

A straight-eyed needle (trailling and leading) was advanced through the drill hole and through the
                                                                                                                                                                                                                                                  Suture Anchor Barnes,                                      1           Surface                             -                    -                    -              -         -
posterior forearm (Fig 2a). Tension on the lead suture delivers the Endobutton, to the cortical                                                                                                                                                                 Lintner
                                                                                                        Fig 1. Endobutton attached with two No 5 Ethibond Bunnel sutures.
window (Fig 2b). Tension on the trailing suture will lock the Endobutton on the dorsal radius (Fig
                                                                                                                                                                                                                                                  Endobutton                    Bain                         1           Medullary                           -                    -                    -              +         +
2c). Fluoroscopy was used to monitor the position.1

Post-operative management
A plaster back slab was removed after one week and the patient provided with a sling and advised                                                                                                                                                 REFERENCES
that the elbow can be mobilised. No heavy lifting for three months.
                                                                                                                                                                                                                                                 1. BAIN, G. I.; HUNT, J.; and MEHTA, J. A.: Operative Fluoroscopy in Hand and Upper Limb Surgery. JBJS, 22B: 5: 656-658, 1997.

RESULTS                                                                                                 Fig 2a. "Prefabricated" tendon prepared for                                             Fig 2b. Leading suture advances Endobutton and
                                                                                                                                                                                                                                                 2. DOBBIE, R. P.: Avulsion of the lower biceps brachii tendon. Analysis of fifty-one previously unreported cases. Am J Surg, 51: 662-83., 1941.

                                                                                                                                                                                                                                                 3. FAILLA, J. M.; AMANDIO, P. C.; and MORREY, B. F.: Post traumatic proximal radio-ulnar synostosis. Results of surgical treatment. JBJS, 71A: 1208-113., 1989

                                                                                                                                                                                                                                                 4. JAUREGUITO, J. W. and PAULOS, L. E.: Why grafts fail. Clin Orthop, 325: 24-41., 1996.

We performed this technique on 11 acute ruptured and 1 delay presentation. All patients were            proximal radius.                                                                        tendon.                                          5. LEIGHTON, M. M.; BUSH-JOSEPH, C. A.; and BACH, B. R.,JR.: Distal biceps brachii repair. Results in dominant and nondominant extremities. Clin Orthop, 322: 116-19., 1995.

                                                                                                                                                                                                                                                 6. MEHERIN, J. M. and KILGORE, E. S.: The treatment of ruptures of the distal biceps brachii tendon. Am J Surg, 99: 636-40., 1960.

satisfied, returned to activities and had return of grade 5 strength. There were no neurological                                                                                                                                                 7. MORREY, B. F.; ASKEW, L. J.; AN, K. N.; and DOBYNS, J. H.: Rupture of the distal tendon of the biceps brachii. A biomechanical study. JBJS, 67A: 418-21., 1985.

                                                                                                        Acknowledgment:                                                                                                                          8. NORMAN, W. H.: Repair of avulsion of insertion of biceps brachii tendon. Clin Orthop, 193: 189-94., 1985.
                                                                                                        Kristen Spears for preparation of this poster
injuries, synostosis or infections. Average flexion was from 3º to 143º with 81º supination and 76º     The Department of Anatomy, University of Adelaide, for providing the cadaveric specimens.


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